Basic Information
| Provider Information | |||||||||
| NPI: | 1861873085 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EXPRESS FAMILY CARE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7117 W WILSHIRE BLVD | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731325575 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4054701224 | ||||||||
| FaxNumber: | 4052170063 | ||||||||
| Practice Location | |||||||||
| Address1: | 7117 W. WILSHIRE BLVD | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 73132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4054701224 | ||||||||
| FaxNumber: | 4052170063 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2015 | ||||||||
| LastUpdateDate: | 02/13/2020 | ||||||||
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| AuthorizedOfficialLastName: | TISDALE | ||||||||
| AuthorizedOfficialFirstName: | JIMMY | ||||||||
| AuthorizedOfficialMiddleName: | LEE | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4054701224 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | APRN | ||||||||
| NPICertificationDate: | 02/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | F0613916 | OK | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
No ID Information.